key: cord-0693532-ovnoo0j1 authors: Lee, Ryan; Hsu, Robert title: Acute aortic occlusion associated with COVID‐19: A rare complication of a not so rare disease date: 2022-04-29 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12730 sha: 5476644f01dcfd6a66d0a29e7c85d7ca77df4c20 doc_id: 693532 cord_uid: ovnoo0j1 Recent literature has reported a high prevalence of thrombotic events associated with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) responsible for causing coronavirus disease 2019 (COVID‐19) infection. Although venous thromboembolism complications have been well studied, arterial thrombosis is less well described. Our aim is to describe acute aortoiliac occlusion (AAO), itself a rare condition, as a complication of COVID‐19 infection and review existing literature regarding its presentation and available treatment modalities. Over a 2‐week span in late 2021, 2 patients with recent COVID‐19 infection presented to our tertiary care hospital with AAO. Each case was treated with a multimodal therapeutic approach, including vascular interventional radiology guided thrombolysis, vascular surgical approach, and systemic anticoagulation. Although two separate primary approaches were taken, each resulted in high morbidity and death in both cases. Acute aortic occlusion is a rare disease associated with high morbidity and mortality. COVID‐19 has further been associated with arterial thromboembolic complications, including AAO, as presented here. More research is needed to identify patients at highest risk of developing arterial thromboembolic disease after COVID‐19 infection as well as to determine ideal therapeutic options in order to improve the exceedingly high morbidity and mortality associated with this complication. Recent literature has reported a high prevalence of thrombotic events associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) responsible for causing coronavirus disease 2019 (COVID- 19) infection. Although venous thromboembolism complications have been well studied, arterial thrombosis is less well described. Our aim is to describe acute aortoiliac occlusion (AAO), itself a rare condition, as a complication of COVID-19 infection and review existing literature regarding its presentation and available treatment modalities. Over a 2-week span in late 2021, 2 patients with recent COVID-19 infection presented to our tertiary care hospital with AAO. Each case was treated with a multimodal therapeutic approach, including vascular interventional radiology guided thrombolysis, vascular surgical approach, and systemic anticoagulation. Although two separate primary approaches were taken, each resulted in high morbidity and death in both cases. Acute aortic occlusion is a rare disease associated with high morbidity and mortality. COVID-19 has further been associated with arterial thromboembolic complications, including AAO, as presented here. More research is needed to identify patients at highest risk of developing arterial thromboembolic disease after COVID-19 infection as well as to determine ideal therapeutic options in order to improve the exceedingly high morbidity and mortality associated with this complication. acute aortic occlusion, anticoagulation, COVID-19, hypercoagulable, thromboembolism The thrombotic complications of coronavirus disease 2019 COVID-19 have been widely reported. Most research and meta-analyses to date have focused on the risk of venous thromboembolism. [1] [2] [3] [4] More rarely, COVID-19 has been associated with arterial thrombosis. 5-7 Acute aortoiliac occlusion (AAO) is itself a rare condition with an incidence estimated to be 3.8 per 1 million person-years. 8 Mortality ranges from 17% to 52% with optimal management strategies not yet well defined. 7, 9, 10 Supervising Editor: Faheem Guirgis, MD. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. Vitals were notable for a heart rate of 102, blood pressure of 122/100, O 2 saturation in the low 80s on room air improving to 93% on 15 L/min non-rebreather mask. He was noted to be in severe distress, moaning secondary to pain. Bilateral lower extremities had decreased sensation, absent motor function, and were cool without any pulses. The right lower extremity was mottled, but the left was not (Figure 1 ). At the time of presentation bilateral lower extremity compartments were noted to be soft. Labs were notable for a leukocytosis of 18. The patient had a prolonged hospital stay complicated by the development of heparin-induced thrombocytopenia, multidrug resistant bacteremia, and multisystem organ failure and was ultimately transitioned to comfort care before death. We have presented 2 patients with AAO associated with COVID-19. Given its rarity, physicians must have a high index of suspicion by considering both historical risk factors and physical examination findings to appropriately diagnose and treat. Atherosclerosis is the most common cause of both peripheral arterial disease and thrombotic aortoiliac occlusive disease and thus the risk factors are similar: smoking, age, family history, diabetes, hypertension, and hyperlipidemia. The most common cardiac risk factors for embolic disease include atrial fibrillation, congestive heart failure, and mitral valve disease. 10 Prior aortic surgery also appears to be a risk factor with graft/stent occlusion occurring in approximately 15% of cases. 8 Aortic aneurism involvement appears to be a less common etiology secondary to earlier surgical management than in earlier decades. 10 Clinical presentation is often sudden and characterized by lower extremity pain, paralysis, paresthesia, poikilothermia, and mottled extremities. CT angiography is currently the preferred imaging study. Prior studies have noted that neurology consultation is often obtained before vascular surgery given that patients often emphasize their motor or sensory deficits, thus delaying time to diagnosis and definitive treatment. 9, 16 This delay in diagnosis and appropriate specialist consultation is important as both mortality and morbidity are related to the duration of ischemia as well as the complications of reperfusion injury. 17 The expected timing of arterial thromboembolic events is uncertain. In a retrospective analysis of COVID-19 patients with limb vascular ischemia, the median time from onset consistent with infection to the development of limb ischemia was 19 days (11-23 days) and another case series reported incidence between days 7-24. 17 In conclusion, a growing volume of literature has reported on the association of COVID-19 infection with thromboembolic complications. Arterial complications including acute aortic occlusion are rarer, less well described, and with less clear ideal treatment options. Timely diagnosis is of the utmost importance and relies on awareness of its presentation, evaluation, and appropriate specialist consultation. Given the morbidity and mortality associated with acute aortic occlusive disease described here, more research is needed to identify patients at highest risk of developing arterial thromboembolic disease, as well as to determine and clearly define ideal therapeutic approaches for this patient population. 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